Special Issue On " Medical and Surgical Ophthalmology" : OPEN ACCESS www.scidoc.org/IJOES.

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International Journal of Opthalmology & Eye Science (IJOES)

ISSN : 2332-290X

Clinical Study of Primary Ocular Tuberculosis

Research Article

Tanushree V1*, Venkate Gowda HT2

1
Senior Resident, Department of Ophthalmology, Mysore Medical College and Research Institute, Mysore, India.
2
Professor and HOD, Department of Ophthalmology, Mysore Medical College and Research Institute, Mysore, India.

Abstract

Introduction: Primary Ocular Tuberculosis describes an infection by the M. tuberculosis species that can affect any part of
the eye (intraocular/extraocular) without any systemic manifestations.
Materials and Methods: Prospective Study was conducted in a tertiary care hospital on patients diagnosed to have primary
ocular tuberculosis attending the outpatient and inpatient department of ophthalmology.
Results: In our study we reported 7 cases of primary ocular tuberculosis. Tuberculosis of eyelid (1 case), Tuberculosis of
conjunctiva (2 cases), Tuberculosis of lacrimal sac (2 cases), Tuberculsois of uvea presenting as acute non granulomatous
anterior uveitis with iris granuloma (1 case) and infectious tubercular scleromalacia perforans (1 case).
Conclusion: Since ocular tuberculosis is treatable and eyes can be saved using anti-tuberculous treatment if detected early,
considerable stress should be laid on its early diagnosis and prompt treatment so as to prevent ocular morbidity and blind-
ness.

Keywords: Primary Ocular Tuberculosis; Secondary Ocular Tuberculosis; Tuberculosis of Lacrimal SAC; Tuberculosis
of Iris.

Introduction TB may not have diagnosed pulmonary TB Ocular TB may be an

initial presentation of extrapulmonary dissemination of infection.
Tuberculosis (TB) is an infection caused by Mycobacterium tubercu- Posterior uveitis is the most common presentation of intraocular
losis, which can cause disease in multiple organs throughout the TB.
body, including the eye. The term Primary Ocular Tuberculosis
describes an infection by the M. tuberculosis species that can affect The gold standard for diagnosing intraocular TB is demonstration
any part of the eye (intraocular/extraocular) without any systemic of Mycobacterium tuberculosis from the intraocular fluid or tissues by
manifestations. Secondary ocular TB is defined as ocular in- microbiological or histopathological examination. The currently
volvement as a result of seeding by hematogenous spread from a available laboratory methods provide an indirect evidence of tu-
distant site or direct invasion by contiguous spread from adjacent bercular etiology of uveitis. The diagnosis of intraocular TB still
structures, like the sinus or cranial cavity. remains largely presumptive as the ocular tissue is rarely sampled.
The use of specific clinical signs as markers predicting TB as the
TB is an airborne communicable disease that most commonly cause of uveitis in a TB endemic area has been recently reported.
involves the lungs. Nearly one third of the worlds population is Definitive diagnosis of extraocular TB in a patient with uveitis
latently infected with TB, and more than 9 million new cases are also aids in diagnosing intraocular TB.
diagnosed each year, 95% in developing countries.
Intraocular TB has a wide clinical spectrum that may include
Ocular TB may not be associated with clinical evidence of pulmo- uveitis, retinal vasculitis, serpiginous like choroiditis, choroidal
nary TB up to 60% of patients with evidence of extrapulmonary tubercles or granuloma, subretinal abscess, or panuveitis. The
rare manifestations include endophthalmitis, panophthalmitis and

*Corresponding Author:
Dr.Tanushree V,
Senior Resident, Department of Ophthalmology, Mysore Medical College and Research Institute, #1128, 1st cross, Paduvana road, T.K.layout, Kuvempunagar, Mysuru: 570023,
Karnataka, India.
Tel: +919481438530
E-mail: tanushree19686@gmail.com

Received: June 11, 2016

Accepted: July 07, 2016
Published: July 08, 2016

Citation: Tanushree V, Venkate Gowda HT (2016) Clinical Study of Primary Ocular Tuberculosis. Int J Opthalmol Eye Res, S8:001, 1-4.

Copyright: Tanushree V 2016. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribu
tion and reproduction in any medium, provided the original author and source are credited.

Tanushree V, Venkate Gowda HT (2016) Clinical Study of Primary Ocular Tuberculosis. Int J Opthalmol Eye Res, S8:001, 1-4.
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Special Issue On " Medical and Surgical Ophthalmology" : OPEN ACCESS www.scidoc.org/IJOES.php

neuroretinitis. Extraocular manifestations commonly in the lid

and adnexa has also been described. In this case a 26 year old patients presented with pain and redness
in right eye since 15 days. On ocular examination acute non gran-
Immunocompromised individuals may have atypical presenta- ulomatous anterior uveitis with vacularized iris granuloma was
tions like hypopyon uveitis, or endophthalmitis. present in the temporal part of Iris. Biopsy was taken from the iris
granulomatous lesion and sent for histopathological examination.
The aim of this study is to note the clinical manifestations in pa-
tients with primary ocular tuberculosis without any other systemic
manifestations involved.

Materials and Methods

Source of Data Collection

Study was conducted in a tertiary care hospital on patients diag-

nosed to have primary ocular tuberculosis attending the outpa-
tient and inpatient department of ophthalmology Figure 2. shows histopathological picture of iris granuloma show-
ing features of tuberculosis.
Method of data collection
HPE report showed sections of Iris tissue containing loose con-
Sample Size: The number of cases which will meet the inclusion nective tissue with underlying loose fibrous tissue, lymphocytes,
criteria during study period. multinucleated giant cells, histiocytes and epitheloid cells form-
ing granuloma. Special stains for Acid fast bacilli was positive.
Study Type: Prospective. Features were consistent with tubercular granuloma. The patient
Study Period: 2012- 2015 was advised antitubercular treatment for 9 months with topical
Inclusion Criteria: All patients with primary Ocular Tubercu- steroid eye drops.
losis.
Exclusion Criteria: All patients with pulmonary and extrapul-
monary tuberculosis other than ocular tuberculosis.

Method of Study

Assessment of clinical presentation of all patients with diagnosed

ocular Tuberculosis by clinical and histopathological study with-
out any pulmonary/extrapulmonary other than ocular tuberculo- Figure 3. shows tuberculosis of conjunctiva who has developed
sis. All patients with confirmed ocular tuberculosis received stand- symblepharon with recurrent dacryocystitis with osteomyelitis of
ard antitubercular treatment along with routine ocular treatment. lacrimal bone. The patient underwent dacryocystectomy with an-
titubercular treatment for 9 months.
Statistical Methods

The study was analysed by Descriptive statistics and Independent

t tests.

Results

In our study we reported 7 cases of primary ocular tuberculo-

sis. Tuberculosis of eyelid (1 case), Tuberculosis of conjunctiva
(2 cases), Tuberculosis of lacrimal sac (2 cases), Tuberculsois of
uvea presenting as acute non granulomatous anterior uveitis with
iris granuloma (1 case) and infectious tubercular scleromalacia Figure 4. shows tuberculosis of the lacrimal sac with fistula for-
perforans (1 case). mation (post Incision and curettage).

In this case 18 year old female patient presented with chief com-
plaints of swelling and pain in the right lacrimal sac region since
two months. History of watering in right eye since 1 year. She was
posted for incision and drainage. On opening abcess there was no
evidence of pus but granulation tissue found which was curated
and sent for HPE, which revealed tuberculosis of the lacrimal
sac. Patient was stared on ATT. In this reported case there is no
Figure 1. shows tuberculosois of uvea presenting as acute non infection of the neighbouring tissue or could tuberculous lesion
granulomatous anterior uveitis with iris granuloma. be uncovered elsewhere in the body after thorough diagnostic in-

Tanushree V, Venkate Gowda HT (2016) Clinical Study of Primary Ocular Tuberculosis. Int J Opthalmol Eye Res, S8:001, 1-4.
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Special Issue On " Medical and Surgical Ophthalmology" : OPEN ACCESS www.scidoc.org/IJOES.php

vestigation. cells forming granuloma. Special stains for Acid fast bacilli is posi-
tive. Features consisent with scleral tuberculosis.

Discussion

Tuberculosis is a ubiquitous disease and a major public health

problem in developing countries like India. The frequencies of
ocular TB in patients with uveitis and systemic TB are respec-
tively 0-0.16% and 0.27-1.4% [1, 2]. The incidence of ophthalmic
manifestations in patients known to have systemic tuberculosis is
only 1-2% [3]. Tuberculosis remains the worlds leading infectious
Figure 5. Shows HPE report lacrimal sac curette sample showing
cause of death and can also cause a variety of diseases through-
features of tuberculosis.
out the body and the eye. Worldwide there are approximately 8
million new cases and 3 million deaths from tuberculosis each
year. Approximately one third of the worlds population has been
infected. The demographics of infection vary widely, with devel-
oping countries bearing the heaviest burden of disease.

In the United States in 1953, the annual risk of being infected

with tuberculosis was 53 per 100000 members of the population
[4]. This decreased to 9.4 per 100000 by 1984, and the World
Health Organization set a goal of eliminating tuberculosis world-
wide. There was a resurgence in the United States to a peak of
10.5 per 100 000 by 1992 ; the reported incidence then declined to
Figure 6. Shows Infectious Tubercular scleromalacia perforans.
5.1 per 100 000 in 2003 [5]. Ocular tuberculosis has always been
considered rare, yet its incidence has varied widely across time,
In this case 77 yr old female patient presented with forward pro-
patient populations, and geography. In 1967, Donahue reported
trusion, bluish discolouration and loss of vision in the left eye
an incidence of ocular tuberculosis of 1.46% in 10524 patients
since 2 years.
from a tuberculosis sanitarium [6].
Ocular examination (LE) showed:
A prospective study from Spain, reported in 1997, examined 100
randomly chosen patients with proven systemic tuberculosis and
* Eccentric proptosis.
found ocular involvement in 18 patients (18%) [7]. In Malawi,
* Diffuse extensive scleral thinning more marked nasally
Africa, a 2.8% incidence of choroidal granuloma in 109 patients
than temporally with exposure of the underlying uvea with
with fever and tuberculosis was reported in a prospective study
vascular engorgement over the thinned out scleral surface.
in 2002 [8]. In India, in a study conducted from January 1992 to
* Cornea was hazy with necrotic scleral plaques near the lim-
December 1994, 0.6% of uveitis cases were believed to be caused
bus without vascular congestion, anterior chamber was flat
by tuberculosis.
and other details were not made out.
* Restriction of extraocular movements was present.
In Japan, a prospective case series from April 1998 to August
* Vision: No perception of light
2000 reported that 20.6% of 126 patients with uveitis had a posi-
tive purified protein derivative (PPD) skin test result, and 7.9%
The patient underwent enucleation followed by artificial eye
were thought to have intraocular tuberculosis. In Saudi Arabia,
implantation after 3 months for cosmetic purpose. Enucle-
during the period from 1995 to 2000, tuberculosis was the cause
ated eye ball was sent for Histopathological examination.
in 10.5% of uveitis cases seen in a referral center [9]. In Boston,
0.6% of patients with uveitis from 1982 to 1992 were believed to
have tuberculosis as an underlying cause [10].

Human immunodeficiency virus (HIV) has contributed to the in-

crease in the incidence of tuberculosis worldwide; HIV increases
the risk of development of active tuberculosis in patients infected
with Mycobacterium tuberculosis. However, rates of ocular tuberculo-
sis in patients with tuberculosis with or without HIV are variable.
In a study reported in 1993 of autopsy eyes from 235 patients
with AIDS, intraocular tuberculosis was found in only 2 eyes. The
Figure 7. shows HPE report suggesting features of scleral tuber- effect of HIV on the immune system can influence both the di-
culosis. agnosis, by reducing the response to PPD testing, and the success
of treatment.
HPE report showed sections of episclera and sclera containing
loose connective tissue with underlying loose fibrous tissue, lym- EE Egbagbe AE, AE Omoti (2008) reported tuberculosis is a
phocytes, multinucleated giant cells, histiocytes and epitheloid cause of ocular morbidity, visual impairment and blindness. Pre-

Tanushree V, Venkate Gowda HT (2016) Clinical Study of Primary Ocular Tuberculosis. Int J Opthalmol Eye Res, S8:001, 1-4.
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Special Issue On " Medical and Surgical Ophthalmology" : OPEN ACCESS www.scidoc.org/IJOES.php

vention, early diagnosis and early treatment of TB may prevent

avoidable visual loss [11]. References
Aliyu Hamsa Balarabe and Jotirmay Biswas (2015) reported the [1]. Copeland RA Jr (1993) The classics: Tuberculosis, Syphilis and sarcoidosis.
importance of a detailed ocular, systemic and laboratory evalua- Ophthalmol Clin North Am 6: 69-80.
[2]. Helm CJ Holland GN (1993) Ocular tuberculosis. Surv Ophthalmol 38(3):
tion to exclude TB in patients presenting with serpigenous cho- 229-256.
roiditis particularly if there is delay in clinical response despite [3]. Demirci H, Shields CL, Shields JA,Eagle RC (2004) Ocular tuberculosis
appropriate treatment [12]. masquerading as ocular tumours. Surv ophthalmol 49(1): 78-89.
[4]. Espinal MA, Laszlo A, Simonsen L (2001) Global trends in resistance to
antituberculosis drugs: World Health Organization-International Union
P Lalitha, SR Rathinam, M Srinivasan (2004) reported that early Against Tuberculosis and Lung Disease Working Group on Anti-Tubercu-
clinical recognition and prompt laboratory diagnosis together losis Drug Resistance Surveillance. N Engl J Med 344(17): 1294- 1303.
with aggressive topical antibiotic therapy may shorten morbidity [5]. Donahue HC (1967) Ophthalmologic experience in a tuberculosis sanato-
and improve the clinical outcome of non tuberculous mycobacte- rium. Am J Ophthalmol 64(4): 742- 748.
[6]. Beare NA, Kublin JG, Lewis DK (2002) Ocular disease in patients with tu-
rial ocular infection [13]. berculosis and HIV presenting with fever in Africa. Br J Ophthalmol 86(10):
1076- 1079.
Conclusion [7]. Biswas J, Narain S, Das D, Ganesh SK (1996) Pattern of uveitis in a referral
uveitis clinic in India. Int Ophthalmol 20(4): 223- 228.
[8]. Morimura Y, Okada A, AKawahara S (2002) Tuberculin skin testing in
Ocular tuberculosis may occur in the absence of any systemic uveitis patients and treatment of presumed intraocular tuberculosis in Japan.
disease and the patients may present with a wide variety of clinical Ophthalmology 109(5): 851- 857.
signs. Also, the disease can mimic several clinical entities. Tuber- [9]. Islam SM, Tabbara KF (2002) Causes of uveitis at The Eye Center in Saudi
Arabia: a retrospective review. Ophthalmic Epidemiol 9(4): 239- 249.
culosis may affect all ocular tissues; choroiditis being the most [10]. Rodriguez A, Calonge M, Pedroza-Seres M (1996) Referral patterns of uvei-
common ocular manifestation. The retinal involvement occurs tis in a tertiary eye care center. Arch Ophthalmol 114(5): 593- 599.
secondary to the underlying choroidal infection. The extraocular [11]. Egbagbe EE, Omoti AE (2008) Ocular disorders in adult patients with tu-
manifestations of the lid and adnexa has been rarely described berculosis in a tertiary care hospital in Nigeria. Middle East Afr J Ophthal-
mol 15(2): 73-76.
in the recent review of literature. Treatment for ocular tubercu- [12]. Balarabe AH, Biswas J (2015) Presumed tuberculous choroiditis:Unusual
losis is the same as that for pulmonary tuberculosis. Due to the presentation and review of the literature. Saudi J Health Sci 4(2): 79-81.
emergence of drug resistance, multidrug therapy is advocated. In [13]. Lalitha P, Rathinam SR, Srinivasan M (2004) Ocular infections due to non
the present time of the HIV pandemic, there has been a resur- tuberculous mycobacteria. Indian J Med Microbiol 22(4): 231-237.
gence of tuberculosis and it is the most common opportunistic
infection in HIV positive patients. HIV related TB shows a higher
Special Issue on
prevalence of extrapulmonary and disseminated TB. In our cas-
es no HIV positive cases has been reported. Since the disease is
"Medical and Surgical Ophthalmology"
treatable and eyes can be saved using anti-tuberculous treatment
Edited by:
if detected early, considerable stress should be laid on its early Gareth Lema, University at Buffalo, NY, USA.
diagnosis and prompt treatment so as to prevent ocular morbidity E-mail: garethmlub@gmail.com
and blindness.

Tanushree V, Venkate Gowda HT (2016) Clinical Study of Primary Ocular Tuberculosis. Int J Opthalmol Eye Res, S8:001, 1-4.
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